Study: Primary care accessibility varies by insurance status

About Elana Gordon

Elana is the newest member of WHYY's Health & Science desk, hailing from KCUR 89.3FM in Kansas City, Mo. where she covered the health beat for several years. Her passion for storytelling and bridging the personal with the abstract has taken her to the backs of school buses, hospital kitchens, and tick infested rural fields. During her tenure at KCUR she won three Regional Edward R. Murrow Awards for her features about domestic violence, health care for the homeless and accordions. Yep, accordions.

Elana is a fellow with NPR and Kaiser Health News' Reporting Project on Health Care in the States. Her work has been featured on programs including All Things Considered, Morning Edition, Kaiser Health News, PRI's The World, The Kansas City Star and Dos Mundos Bilingual Newspaper. Before taking the plunge into radio, she worked as a prevention specialist at a health clinic. She holds a dual degree in political science and music from Barnard College. It was there that she first caught the radio bug as an occasional host/producer for the music program, In All Languages, on WKCR 89.9 FM.

Researchers posing as non-elderly adult patients made nearly 13,000 calls to primary care practices across Pennsylvania, New Jersey and eight other states between Fall 2012 and spring of last year.

What they found may provide at least some comfort amid growing concerns of doctor shortages, especially as more people gain coverage through the Affordable Care Act and potentially straining the health system even more.

Dr. Karin Rhodes, from the University of Pennsylvania and a lead on the study published this week in JAMA Internal Medicine, says when researchers said they had insurance, they were able to make an appointment about 85 percent of the time. On the first try, no less.

"Capacity exists. I think this is a very optimistic message," Rhodes said, adding that researchers were usually able to get scheduled within a week. The median wait in Massachusetts was about two weeks.

While the study relied on direct simulated patient experiences as opposed to self-reported doctor surveys, Rhodes acknowledges it did not examine the quality of care received, the accessibility for returning patients or the role of cost in determining patients' real access to services.

Rhodes says overall accessibility documented through the study is encouraging, but it did vary based on whether researchers identified as having insurance or Medicaid. Those calling as Medicaid patients were successful getting appointments about 60 percent of the time on the first try, compared to that 85 percent success rate as privately insured. When calling with Medicaid coverage, they only contacted select providers listed as accepting Medicaid.

In further examining national patient surveys and subsets of those research calls that honed in on community health centers, Rhodes found that Medicaid variation did not majorly impede access to primary care, although people had fewer choices of providers.

Dr. Andrew Bindman and Janet Coffman of the University of California, San Francisco, worry about how this will play out as more people gain Medicaid coverage. In an accompanying editorial, they emphasized that fewer doctors accept Medicaid and those that do only take a limited number of patients.

"Safety-net clinics provide a disproportionate amount of care to patients covered by Medicaid, which helps fill some of the void, but this approach is insufficient on its own, particularly for meeting the needs for specialty care," they wrote.

Beyond those with Medicaid and the privately insured, availability dropped a lot for those who said they were uninsured and couldn't pay much out of pocket. Researchers were four times less likely to get in compared with those calling with Medicaid.

New primary care models helping alleviate demand

Rhodes says the study provides "a baseline" for better tracking primary care access, and that it will be important to monitor changes as more people gain coverage under the Affordable Care Act and an expansion of Medicaid in select states moving forward with that policy.

Massachusetts providers reported being overwhelmed when the state expanded coverage in 2006, but Rhodes points out that nationwide, it has the highest percentage of its population — more than 90 percent — reporting to have a regular source of care.

As for doomsday tales of doctor shortages in years to come, national surveys point to the problems growing but perhaps not as dire as previously pictured in primary care. Christiane Mitchell, federal policy director with the Association of American Medical Colleges, says physician shortages are of real concern, with projections in primary care falling short by about 45,000 doctors by 2020. At the same time, she says changing approaches are helping to alleviate the growing demands and boost the field.

"There are new models that use different types of providers that are not physicians," Mitchell said, whether that be ones that rely more on nurse practitioners or create more team approaches to care. "And there are new payment systems that make sure primary care physicians feel that they're being paid appropriately."

Mitchell says Massachusetts is a prime example of making such changes and better handling an influx of patients. The Affordable Care Act also incorporates some of these policies.

Dr. Douglas Spotts, a Lewisberg doctor and President of the Pennsylvania Academy of Family Physicians, said he is "very encouraged" by Rhode's study. He says the takeaways echo a survey snapshot from his own group on primary care access in Pennsylvania, which found that 98 percent of respondents see and treat patients who don't have insurance and nearly 95 percent see Medicaid patients.

"I'm actually encouraged that some of those people we're already seeing will now have [ACA] insurance," Spotts said.

Rhodes, with Penn, says given the available capacity, helping patients navigate the current system and find accessible practices based on their insurance situation will be especially important in the coming months and years, as will monitoring the availability, affordability and quality of care as more people gain coverage.

"The is just one piece of the elephant," Rhodes said. "But I think this is an important piece, to get the patient experience when they call up."

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